Thyroid disease: Medical or surgical Thyroid diseases management?

DONALD L. SMITH, D.O., FACOS Flint, Michigan

Still, the surgeon is needed for benign and malignant tumors and occasional thyroiditis, and until their eti- There is no consensus on the treatment of ology is understood, surgeons must continue to be educated in the refinements of thyroid surgery. thyroid diseases, but it is the present authors belief that thyroid nodules as a Adenomas rule are surgical problems. In children the Among the questions that remain to be an- incidence of carcinoma in nodular goiter is swered, however, according to Beahrs,3 is the high, and the reasons for not operating relation between adenomatous goiter and can- must be strong. Thyroiditis usually is a cer of the thyroid gland; nodular goiter is com- medical problem, and the diagnosis can be paratively frequent and cancer of the thyroid confirmed by needle biopsy. Occasionally it is comparatively rare. It is found in 5 percent necessary to remove the isthmus which of nodular goiters, according to Beahrs.3 constricts the trachea. Hyperthyroidism Scanning of the thyroid gland with either may be managed with radioactive iodine in radioactive iodine-131 (1131) or technetium- patients of all ages. Only pregnant women 99m (Tc88m ) has made it possible to differen- should be treated with antithyroid drugs. tiate hyperactivity within the gland from ex- trathyroid adenoma. In the presence of a hyperactive adenoma or adenomas of the thyroid gland, thyroid-stimulating hormone (TSH) is reduced and normal thyroid tissue will be suppressed. Correction of this hyper- activity by removal of nodules will permit the It has been almost 20 years since Dr. Taverner remaining normal thyroid cells to revert to and I collaborated on a paper on the surgical normal activity even after years of suppres- management of diseases of the thyroid gland,1 sion. The TSH stimulation test is performed and in spite of advances in diagnosis in the by administering 10 units of TSH either intra- intervening years, diseases of this gland re- venously or intramuscularly and scanning the main a perplexing problem. gland with I 131 or some other suitable isotope Scanning has made it possible to distinguish 24 hours later. The TSH suppression test is thyroid nodules from normally functioning carried out by scanning the gland after giving tissue and to differentiate between nodules the patient 25 micrograms of triiodothyronine that do not take up radioactive iodine (cold (T-3) three times a day for 8 days or 0.3 mg. nodules) and those that do (hot nodules). of levothyroxine or 200 mg. of thyroid extract Which patients to operate on and which to per day for 10 days. Thyroid extract is the treat medically and the extent of surgery re- least desirable agent to use for suppression main problems on which differences of opinion of TSH, because it contributes a tremendous persist and demand the best judgment of the amount of inorganic iodine to the gland. surgeon. Cope2 stated : Hyperfunctioning thyroid nodules usually The treatment of goiter is in transition from surgical occur in women past 30 and often are undiag- to medical and preventive. Fifty years ago thyroidecto- my was one of the commonest operations. . . . Today nosed unless another condition, such as atrial the operation has become one of the less needed. . . . fibrillation, develops and prompts a search for

Journal AOA/vol. 73, April 1974 624/71 Thyroid disease

the etiologic factor. Thyrotoxic adenomas act amination of tissue, and needle biopsy is in- independently of TSH and are not under its dicated when the condition is suspected. influence. Therefore, suppression of TSH with The treatment is primarily medical, with T-4, T-3, or thyroid extract is of no therapeutic administration of Proloid (thyroglobulin), a value. The occasional patient who reacts fa- purified extract, or Euthroid, a synthetic with vorably to thiourea will experience a return a ratio of 4 :1 of T., and T3. The patient should of symptoms as soon as the drug is discon- be observed cautiously because of the possi- tinued. I131 is effective in treatment of toxic bility of carcinoma. Beahrs and Pasternak adenomas in only about 30 percent of patients. stated that papillary cancer occurred in ap- It is indicated, however, for elderly patients, proximately 3 percent of patients with thy- those who refuse surgery, and those with a roiditis treated at the Mayo Clinic and that limited life span. lymphosarcoma was present in another 3 per- Before surgery many patients with toxic cent. thyroid adenoma will require little or no prep- Hashimotos thyroiditis should be treated aration with antithyroid drugs or inorganic with 3 grains of desiccated thyroid, 1 tablet iodine in comparison with patients with diffuse of Euthroid-3, or 3 grains of Proloid per day, Graves disease. The administration of potas- to be continued during the life of the patient. sium iodide for the control of hyperthyroidism Subacute thyroiditis often can be diagnosed in patients with toxic adenomas is not nearly from a history of neck pain, tenderness, ele- as effective as it is in achieving a euthyroid vation of the sedimentation rate, and diffuse state in patients with diffuse Graves disease. or discrete enlargement of the thyroid. Con- If antithyroid drugs are used before removal servative treatment is indicated. Beahrs3 rec- of an adenoma, they should be given in maxi- ommended, however, that if a nodular goiter mum therapeutic doses, and the anesthetic remains after from 3 to 6 months conservative agents used at the time of the surgery should therapy or if there is any increase in its size, be chosen from among those that produce least then it is important that the gland be removed irritability of the heart. Hypoxia must be surgically, to rule out malignant change. avoided, and large doses of narcotics which For subacute granulomatous thyroiditis, suppress respiration should not be given. treatment is with a corticosteroid, 5 mg. of The purpose of surgery is to remove only prednisone four times a day for 4 days, three the toxic adenoma and leave as much normal times a day for 3 days, and then twice a day thyroid tissue as possible. It must be remem- for a period depending on relief of symptoms. bered, however, that the presence of a hyper- This can be determined by giving tracer doses active nodule does not necessarily preclude of radioactive iodine at monthly intervals. the coexistence of a cold nodule that could be When the uptake is high, after low values malignant. The scan often fails to reveal such during the inflammatory phase, probably pred- a cold nodule because of the suppression of nisone therapy can be discontinued. TSH and the radioactivity within the remain- In Reidels struma the gland is firm and ing portion of the gland as a result of the hard. With this type of thyroiditis it is not hyperactive nodule. Adenocarcinoma, as a rule, absolutely necessary that the whole gland be does not develop within the confines of the removed, but the trachea should be freed from hyperactive nodule, but adenocarcinoma at the any thyroid tissue to prevent constrictive rim of the hot nodule is not uncommon. symptoms in that region. If an elderly patient has a nodular goiter that does not increase Thyroiditis in size and is asymptomatic, it need not be Hashimotos thyroiditis usually occurs in wom- removed at once, but a young patient with a en. With this condition the gland is firm and firm discrete or single nodule of short dura- symmetric, and serologic testing for antibodies tion that has increased in size suddenly should suggests the possibility of the disease. Of have it removed.8 This is particularly true if course, the ultimate diagnosis depends on ex- it is a cold nodule.

625/72 Carcinoma eluding the anaplastic, giant cell, pleomorphic Cancer of the thyroid is relatively infrequent cell, and spindle cell cancers; and (c) medul- and may have a prolonged course or may lary carcinoma, which belongs in a class by progress rapidly. Opinions as to its manage- itself. ment differ, and the surgeon is faced with a Papillary cancer may be of pure or mixed multifaceted problem when a patient comes type. Sometimes follicular cells are present, into the office or the surgical service with a and Wychulis and associates 5 reported mixed thyroid nodule that has been detected on rou- papillary and anaplastic cancer in 16 of 162 tine physical examination. tumors classified as anaplastic in the Mayo When the patient is a child, his age is an Clinic series. It is an invasive cancer and is important consideration. Approximately 15 not well encapsulated. It metastasizes to the percent of nodular goiters removed from chil- cervical lymph nodes, but rarely spreads sys- dren are malignant, and in some series the temically. frequency has been as high as 70 percent. How- Woolner and associates" said that in about ever, there is an increasing incidence of Hashi- 10 percent of papillary cancers in the Mayo motos thyroiditis in children, and for this Clinic series no goiter was noted, and cervical reason it should not be concluded that all nodu- adenopathy was the presenting clinical sign. lar goiters in children should be removed. Beahrs and Pasternak said that the primary When a person under age 18 has a thyroid lesion of papillary cancer may be small and nodule, however, the reasons not to operate not palpable and that the first evidence of its must be strong, unless Hashimotos disease is presence in 22 percent of occult lesions in the established by needle biopsy. Malignant change Mayo series was extensive lymphadenopathy is more probable in a single nodule than in in the lateral region of the neck. When biopsy multiple nodules. of the lymph node reveals evidence of papillary When the patient is past 40, he should be carcinoma, the thyroid definitely should be asked about any previous history of radiation explored as a possible primary site of malig- therapy, his family history, and whether the nant change. gland is painful. Many nodules represent hem- Papillary cancer should be treated by total orrhage into a cyst. If the patient, usually lobectomy on the side of the lesion and subtotal female, states that the nodule appeared sud- lobectomy on the opposite side unless the le- denly and that a week before she did not know sion is bilaterally multicentric. In the Mayo it was there, it probably is a cyst, and it can Clinic series,4 when a portion of the thyroid be aspirated in the office to verify this. In gland was left on one side, the incidence of 1949 Crile5 stated that injection of sclerosing tetany was 0.3 percent and of unilateral pa- solutions, reported by Cutler and Zollinger,6 ralysis of the vocal cord, 1 percent. When the had been tried, but that results were unsatis- primary lesion remained intracapsular, even factory. In 1970, however, Crile7 reported that with involvement of the regional lymph nodes, two or three injections of 0.5 ml. sclerosing the prognosis was good and the mortality ex- solution, after aspiration of fluid from the cyst, tremely low. When the tumor extended beyond would cause it to disappear. the capsule, however, and the regional lymph The presence of a hot nodule does not neces- nodes were involved, the mortality was con- sarily exclude the presence of malignant siderably increased. In elderly patients the change and should not carry too much weight condition often is incurable when the regional in the decision to operate. The incidence of lymph nodes are involved. malignancy, however, is greater in cold nod- The indications for surgery for the patient ules. with nontoxic nodular goiter are marked hy- The course of cancer is influenced by its pothyroidism, pressure symptoms, deviation of histologic pattern, which may be classified as : the esophagus producing dysphagia, and sub- (a) differentiated, including the papillary and sternal mass. The incidence of carcinoma is follicular cancers; (b) undifferentiated, in- relatively small, about 5 percent. 3 In patients

Journal AOA/vol. 73, April 1974 626/78 Thyroid disease

who have undergone surgery at Mayo Clinic, thyroid drugs should be begun as soon as the approximately 1 percent have unilateral cord diagnosis of hyperthyroidism is made and paralysis, and 0.3 percent have postoperative should be continued while the cause of the tetany.4 condition is evaluated, after which definitive In some instances it may be desirable to try medical or surgical therapy should be insti- suppression of the thyroid gland with a full tuted. dose of from 0.2 to 0.3 gram of desiccated In my opinion, however, the only patients thyroid, as recommended by Crile." This is who should be given antithyroid drugs today suitable for children, particularly when the are pregnant women, and they should receive tumor extends around the recurrent laryngeal radioactive iodine as soon as the pregnancy is nerve. If the tumor can be shaved off, as it terminated. can in most instances, the recurrent laryngeal According to Skillern, 12 it has been the prac- nerve should not be sacrified even though re- tice at the Cleveland Clinic for the past 15 sidual tumor cells may be left, because in 90 years that all patients with hyperthyroidism, percent of patients with papillary cancer the regardless of their age, be treated with radio- condition can be controlled for an indefinite active iodine. As a rule this includes children period with suppression therapy. Only when between 5 years and adolescence, since chil- the vocal cords are fixed before surgery, with dren under 5 years usually do not show evi- extension of the tumor around the recurrent dence of Graves disease. Hypothyroidism fol- laryngeal nerve, should that nerve be sacri- lows treatment either by surgery or with ficed." radioactive iodine in a significant number of In the average case a thyroid nodule should cases. One reason for this is the high and be excised widely, and sometimes partial lob- increasing incidence of Hashimotos thyroid- ectomy on the involved side with accurate itis. Another reason is the variation in sensi- frozen section study is justifiable. If the pa- tivity of tissue to radioactive iodine. Dr. Skil- thologist is not versed in thyroid diseases, lern has recommended, therefore, that all pa- however, total lobectomy on the involved side tients who are treated with radioactive iodine should be done, and if papillary carcinoma is be given lifetime treatment with a daily dose diagnosed, partial lobectomy on the opposite of 2 grains of desiccated thyroid. There is a side should include the area corresponding to 1 or 2 percent recurrence rate of Graves dis- the one in which the lesion was located. ease after radioactive iodine therapy. There If the malignant lesion is extensive, semi- is, however, no increase in incidence of leu- radical neck dissection is indicated, but stan- kemia in children treated with radioactive io- dard radical neck dissection is not indicated dine, nor is there any evidence of any genetic unless there is extensive nodal involvement or influence at this time. None is anticipated by extension outside the lymph chain or unless the United States Institutes of Health. the patient has had previous surgery that The cost of the therapy with radioactive io- makes removal of adequate tissue difficult. dine for the patient with Graves disease is $200 Radical neck dissection is indicated also for and this includes the therapeutic test. The usu- medullary cancer, which spreads both by direct al dose of radioactive iodine is from 150 to 200 extension to the lymph nodes and systemically. millicuries per gram of thyroid gland." The This is the type that forms amyloid in the physician estimates the weight of the gland. stroma. The 5-year survival rate is about 50 The larger the gland, the more resistant it is percent. to radioactive iodine, and it is important that For anaplastic cancer the prognosis is poor, an adequate dose be given the first time, so and the mortality rate within 1 year is almost that the patient does not have to be treated 100 percent. more than once. Most patients will receive ap- proximately 10 millicuries of radioactive io- Hyperthyroidism dine, but a patient who appears particularly Cope2 recommended that treatment with anti- sick and has evidence of severe Graves disease

627/74 probably will receive 15 or 16 millicuries. For cancer has declined. I do not know why except seriously ill patients, particularly those who possibly that the number of cold nodules re- may be gravely ill from hyperthyroidism, with moved has increased. associated severe cardiac abnormalities, it may There has been a decided increase in pa- be well to start medication with saturated solu- tients operated on for other conditions, in- tion of potassium iodide, 5 drops twice a day, cluding cysts and thyroid remnants. The policy as well as antithyroid drugs." The iodine is to remove surgically any lesion in which the blocks the release of thyroxine. Lugols solu- diagnosis is uncertain, rather than to aspirate tion should not be given because in seriously a cyst, for example. Sclerosing solutions have ill patients it affects the digestive tract, and not been used, and needle biopsies have not it has a high iodine content. Potassium iodide been satisfactory because the Department of does not block the synthesis of thyroid hor- Pathology prefers larger specimens removed mones and is more effective than the anti- surgically. thyroid drugs, which themselves block hor- The records of 566 of the 700 cases in which mone synthesis from 2 to 4 weeks. Potassium operation was done in the past 15 years showed iodide and antithyroid drugs may be started 64 cases of cancer (11 percent), with the fol- simultaneously and the therapeutic dose of lowing distribution : Hiirthle cell cancer, 9; ad- radioactive iodine may be given at this time. enocarcinoma, 7; small cell cancer, 1; papillary The relation between such treatment and thy- cancer, 29; follicular cancer, 12; undifferenti- roid storm has been a subject of considerable ated (anaplastic) cancer, 5; and lymphosar- discussion," but it appears probable that the coma, 1. Of the operations for nonmalignant thyroid storm arises from discontinuance of diseases, 51 (7 percent) were done for Hashi- the antithyroid drug prior to the full effect of motos disease, 3 for Riedels struma, 4 for radioactive iodine or surgery." acute thyroiditis, 39 (6 percent) for Graves disease, 33 for cyst, 312 (55 percent) for non- Experience at Flint Osteopathic Hospital toxic adenomatous goiter, and 60 for toxic Over the past 15 years, slightly more than 700 adenomatous goiter. patients were operated on for thyroid disease, and during the past 5 years 166 patients were operated on. This suggests that fewer patients 1. Taverner, W.H., and Smith, D.L.: Surgical management of are undergoing surgery since the advent of the thy roid gland. JAOA 55:243-7. Dec 55 scanning and the use of radioactive iodine. 2. Cope, 0.: The thyrcid gland. In Manual of preoperative and postoperative care. Edited by J.M. Kinney, R.H. Egdahl, and Of the operations in the past 15 years, 18 per- G.D. Zuidema. Ed. 2. W.B. Saunders Co., Philadelphia, 1971 cent were for cancer, 28 percent for thyroid- 3. Beahrs, 0.11.: Nodular goiter and cancer of the thyroid gland. Postgrad Med 36:229-33, Sep 64 itis, 48 percent for adenomas, and 6 percent 4. Beahrs, O.K., and Pasternak, B.M.: Cancer of the thyroid for other conditions. In the past 5 years the gland. Curr Probl Surg pp. 1-38, Dec 69 5. Crile, G., Jr.: Practical aspects of thyroid disease. W.B. Saun- respective figures were 11, 7, 55, and 27 per- ders Co., Philadelphia, 1949 cent. 6. Cutler, E.C., and Zollinger, R.: The use of sclerosing solutions in the treatment of cysts and fistulae. Am J Surg 19:411-8, Mar 83 This suggests that fewer patients were 7. Crile, G., Jr.: Speech presented at Symposium on Carcinoma of Thyroid, 119th Annual AMA Convention. Reproduced Audio Digest, operated on for thyroiditis because it was rec- Vol. 17, No. 15, 12 Aug 70 ognized more frequently, although the nation- 8. Wychulis, A.R., Beahrs, OIL, and Woolner, Papillary carcinoma with associated anaplastic carcinoma in the thyroid wide incidence of the condition has increased. gland. Surg Gynecol Obstet 120:28-34. Jan 66 The percentage of adenomas operated on was 9. Woolner, L.B.. et al.: Classification and prognosis of thyroid carcinoma. A study of 885 cases observed in a thirty year period. nearly the same, with a slight increase because Am J Surg 102:354-87, Sep 61 the solitary adenoma, whether it is toxic or a 10. Crile, G., Jr.: Endocrine dependency of papillary carcinomas of the thyroid. JAMA 196:721-4, 28 Feb 66 cold nodule, is considered to be a surgical 11. Crile, G.. Jr.: Late results of treatment for papillary cancer problem. Hot nodules do not respond well to of the thyroid. Ann Surg 160:178-82, Aug 64 12. Skillern, P.G.: Speech presented at Postgraduate course in 1131, and surgery is done to avoid harm to the general surgery at Cleveland Clinic. Reproduced Audio Digest- normal gland and to remove all cold nodules. Surgery, Vol. 18, No. 6, 10 Mar 71 13. Beierwaltes, W.H., Keyes, J.W.. Jr., and Carey. J.E.: Manual The percentage of patients operated on for of nuclear medicine procedures. CRC Press, Cleveland, 1971

Journal AOA/vol. 73, April 1974 628/75 14. Zimmerman, L.M., and Levine, R.: Physiologic principles of surgery. W.B. Saunders Co., Philadelphia, 1957 15. Daughaday. W., et al.: Clinicopathologic conference. Thyroid strom shortly after mil therapy of a toxic multinodular goiter. Dr. Smith is presently senior attending Am J bled 52:786-96, Jun 72 surgeon (certified) at Flint Osteco. Arta, C.P., and Hardy, J.D., Eds.: Complications in surgery and pathic Hospital, and consultant sass their management. Ed. 2. W.B. Saunders Co., Philadelphia, 1967 Won at General Hospital. Flint, Mich,. igan. His paper was adapted from material presented at the Fourth An- nual Inquisition Surgical Forum held in Mexico DitY, Feb. 26—March 5. 1972. Dr. Smith, 8122 Clio Road, Flint. Michigan 48504. This study was made possible by a grant from Warner- Chilcott Laboratories, Morris Plains, NJ.